Make Your Care Safer
Educate yourself on the topics below and sign on to support the following three patient safety policy issues:
Driving Safety Data Transparency
Current patient death and injury data are only estimates compiled by researchers. We don’t really know how many people are affected each year. This is because we don’t have an accurate method for measurement and we lack a national and global commitment to standardize metrics. There is no requirement that the frequency and severity of all medical errors, or the resulting patient outcomes, are reported to the public or even to public health authorities.
Care and patient procedures (e.g. hip and knee replacements) are rapidly moving out of the hospital and into ambulatory settings where there is no transparency in place to drive the quality and safety of outcomes, reporting or incentives. The same is true for children’s hospitals and very small hospitals (critical access hospitals) as well. The public has very little insight into which of these facilities are safe.
Death certificates mask the problems by not including “preventable medical error” as either a secondary or primary cause of death. They typically state the diagnosis or underlying condition, such as “myocardial infarction (heart attack)” or “sepsis,” even when treatment or diagnostic failures were the actual cause. Additionally, the death certificate isn’t always completed by someone who has cared for the patient and therefore can sometimes be incorrect and very difficult to change after it is issued.
And, in addition to this gap in surveillance, transparency is impeded by fear. Organizations and clinicians are often fearful to be transparent with patients and families about medical errors that have occurred due to fear of litigation, blame or loss of reputation. A focus on high reliability systems instead of individual blame and transparency of all patient harm and death is key to improving transparency. Programs like CANDOR (Communication and Optimal Resolution), supported by the Agency for Healthcare Research and Quality (AHRQ), when properly implemented, also drive transparency in addition to improving patient outcomes, saving money, and fostering continuous learning. Zero harm is not achievable without transparency as the first step.
There is misalignment between the goals of healthcare organizations, clinicians, payors, and patients. Our current care delivery model was designed to pay for care for existing disease, not to promote wellness and prevent illness. Healthcare organizations and clinicians are generally paid according to the volume of hospitalizations, visits, and procedures completed, rather than by quality and safety-related patient outcomes. This incentivizes unnecessary care or overtreatment, which increases both the cost and risk of harm. In addition, care and procedures (e.g. hip and knee replacements) are rapidly moving to ambulatory settings where the payment policy necessary to drive the quality and safety of outcomes is especially lacking. While there has been much attention to patient safety in the last 20 years and some success around specific risks like central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI), these are just the tip of the iceberg of preventable harm. Despite the best intentions of those on the frontline, we will never reach zero harm in healthcare until financial incentives for healthcare organizations are aligned with the goal of systemic prevention of all-cause harm in all care settings.
Establishing Region-Appropriate Regulatory Oversight Globally
Research and discussion about the need for effective patient safety oversight and legislation have increased in many countries over the past two decades as patients, providers and the press have driven awareness of the alarming risk of unsafe care to public health. Yet few countries have comprehensive programs for reporting, investigation, and collective learning at national or regional levels. A regulatory approach is needed in each country similar to the agencies and boards squarely focused on safety in the aviation and transportation industries, to ensure that provider organizations truly have safety processes and training programs in place. This type of oversight also helps to support a transparent culture of safety in healthcare that enables provider organizations to more rapidly identify risks, learn from each other’s experiences and spread innovative solutions.